Neuro Motor Exam

Front 1

Control Circuits

Back 1

Basal Ganglia
Cerebellum
Thalamus
Brainstem
Interneurons in spinal cord.

Front 2

Things tested in motor exam

Back 2

Strength
Muscle bulk
reflexes
muscle tone
coordination
resting posture
gait

Front 3

Muscle strength scaling (0-5)

Back 3

0=no motion at all
1=can see/palpate movement of muscle but it doesnt move the body
2=can move but not against gravity
3=can counter gravity and nothing more
4=slight weakness
5=normal

(often expanded to a 9 or 13 point scale)

Front 4

Corticospinal tract (upper motor neurons)

Back 4

Voluntary motor function

Front 5

Extrapyramidal system

Back 5

"basal ganglia, etc."

important in resting tones, postures, initiating movement.

Front 6

Pronator Drift

Back 6

Diffuse weakness of the upper limb.

If pronation does not occur with downward drift, probably not organic disease.

(contrast with proprioceptive loss where limb will drift erratically)

Front 7

Breakaway/collapsing weakness

Back 7

Pt will buildup force and then suddenly collapse. Not associated with true neuro injury. Could be due to pain or embellishment.

Front 8

UMN weakness

Back 8

Damage to corticospinal tract.
Will manifest as increased reflexes with a spastic type of increased tone.

Front 9

Lower motor neuron weakess

Back 9

Damage to anterior horn cells or their axons found in peripheral nerves or nerve roots - results in decreased reflexes and muscle tone. And severe atrophy.

Front 10

Nerve roots
Should abduction

Back 10

C5-6

Front 11

Nerve roots
Shoulder ext rotation

Back 11

C5

Front 12

Nerve roots
Elbow flexion

Back 12

C5-6

Front 13

Nerve roots
Elbow extension

Back 13

C7

Front 14

Nerve roots
Wrist flexion

Back 14

C7-8

Front 15

Nerve roots
Wrist extension

Back 15

C7

Front 16

Nerve roots
Intrinsic hand muscles

Back 16

C8-T1

Front 17

Nerve roots
Hip Flexion

Back 17

L2-3

Front 18

Nerve roots
Hip extension

Back 18

L4-5

Front 19

Nerve roots
Knee flexion

Back 19

L5-S1

Front 20

Nerve roots
Knee extension

Back 20

L3-4

Front 21

Nerve roots
Ankle plantar flexion

Back 21

S1-2

Front 22

Nerve roots
Ankle dorsiflexion

Back 22

L4-5

Front 23

Nerve roots
Ankle inversion and eversion

Back 23

L5-S1

Front 24

Muscle disease causing motor weakness usually affects...

Back 24

Proximal (big) muscles

Front 25

Muscle weakness of NMJ usually results in...

Back 25

muscle fatigue.

Front 26

Disuse atropy vs neurogenic atrophy

Back 26

Disuse - reversible. due to something like bedrest or casting. (can be caused by UMN involvement)

Neurogenic - Indicates lower motor neuron involvement

Front 27

Hoover's sign

Back 27

Have pt sit. Hold you hand under one heel. Have pt extend the other leg. If there is pressure from the heel, weakness is legitimite (organic). If no pressure, it is probably non-organic.

Front 28

Motor neuron in the deep tendon monosynaptic spinal reflex - UMN or LMN?

Back 28

LMN

(and note that UMNs inhibit descending motor pathways)

Front 29

Deep tendon reflex scale

Back 29

0 - no response
1 - sluggish
2 - normal
3 - brisk
4 - sustained clonus (always abnormal - ankle is most common)

Front 30

Deep tendon (myotactic) reflexes
Biceps

Back 30

C6

Front 31

Deep tendon (myotactic) reflexes
Brachioradialis

Back 31

C6

Front 32

Deep tendon (myotactic) reflexes
Triceps

Back 32

C7

Front 33

Deep tendon (myotactic) reflexes
Finger flexors

Back 33

C8

Front 34

Deep tendon (myotactic) reflexes
Knee reflex

Back 34

L4 and some L3

Front 35

Deep tendon (myotactic) reflexes
Ankle jerk

Back 35

S1

Front 36

Superficial reflexes
Scratching of skin (foot)

Back 36

Lateral plantar stimulation and across ball of foot will lead to downgoing toe (plantar response)

No response suggests damage to motor tracts or sensory deficit.

If big toe goes up and other toes fan - Babinski sign (normal in newborns)

Abnormal SUGGESTS UMN DAMAGE

If there is no response, is that a LMN lesion?

Front 37

Superficial reflexes
Abdominal reflex

Back 37

Contraction of muscle in quadrant due to scratch of skin

ABSENSE SUGGESTS UMN DAMAGE

Front 38

Superficial reflexes
Cremaster reflex

Back 38

Rapid brief elevation of testicle on side of scratch of medial thigh.

ABSENSE SUGGESTS UMN DAMAGE

Front 39

Bulbocavernosus reflex

Back 39

Prognostic after spinal cord trauma

Anal sphincter contraction in response to squeezing of glans penis or tugging on foley cath.

Involves S1,2,3 nerve roots and is spinal cord mediated.

Persistent loss may be due to conus medullaris injury (L1 burst fracture)

Return in 48 hours usually means spinal shock resulting from cervical or thoracic cord injury.

Front 40

Reflexes - most important factor

Back 40

Symmetry!
(both deep tendon and superficial reflexes)

Front 41

Tromner's or Hoffmann's sign

Back 41

Tromner's - Volar surface (side facing you when in anatomical position) of fingers are tapped)

Hoffman's - flicking fingers and you are looking for flexion of the thumb.

Pathological reflexes in this case are just signs of very brisk myotatic reflexes.

Front 42

Alternatives to the Babinski

Back 42

Oppenheim (ant tibia rub with upgoing plantar)

Chaddock (firm pressure on lateral foot to get upgoing plantar)

Gonda's (extensor plantar response after flicking little toe or 4th toe)

Schafter maneuver (pinching of Achilles tendon)

Front 43

Regressive/primitive reflexes

Back 43

Grasp
Snout
Routing
Palmomental
Glabellar
Nuchocephalic

Front 44

Rigidity

Back 44

Increased muscle tone
Like a lead pipe. Basal ganglia disease (i.e. extrapyramidal disease - often with Parkinson's). Limb doesn't rteturn to normal position

Front 45

Spasticity

Back 45

Increased muscle tone
Clasped-knife. Corticospinal tract (UMN lesions)
With rapid displacement, resistance increases then suddenly relaxes.

Front 46

Paratonia

Back 46

Increased muscle tone
Gegenhalten. Inability to relax. Seen in frontal lobe dysfunction.

Extreme paratonia common with dementia.

Front 47

UMN Exception with muscle tone

Back 47

NORMALLY THEY CAUSE SPASTICITY, BUT ACUTELY THEY CAN CAUSE FLACCIDITY.

And decreased muscle tone also can be due to lower motor neuron damage.

Front 48

Myopathies

Back 48

Muscular dystrophies (usually proximal weakness with normal to diminished reflexes)

And acquired myopathies (usually proximal)

Front 49

Dysdiadochokinesis (coordination)

Back 49

Inability to perform rapidly alternating movements. Often caused by MS in adults or cerebellar tumors in children.

Front 50

Coordination is contra or ipsilateral?

Back 50

Ipsilateral

Front 51

Intention tremor (coordination)

Back 51

Repetitive over and undershoot during voluntary movement.

Front 52

Parkinson's

Back 52

Extreme slowness. Creates false impression of dysdiadochokinesis because it is secondary to something else.
Extrapyramidal disease

Front 53

Chorea

Back 53

Repetitive, brief, jerky movements. (e.g. Huntingtons)

Not tics, which are stereotypied and within the same muscle group.

Front 54

Athetosis

Back 54

Continuous stream of slow, writhing movements o fthe hands and feet usually.

Front 55

Dystonia

Back 55

Sustained twisting of the body. usually trunk and neck. at neck it is called torticollis)

Or with eyes it is rapid blinking/squinting

Or with hand/forearm it is writers cramp.

Often due to an underlying neuro problem (stroke, tumor, infection, etc)

Front 56

Hemiballism

Back 56

Motion of one side of the body potentially resulting in falls.

Front 57

Dystonia therapy

Back 57

Botox (blocks cleavage of SNAP25 and hence binding of synaptosome to cell membrane and release)

Front 58

Resting tremor

Back 58

Usually with PD. Decreases with movement. Extrapyr disease. Frequently asymmetrical.

Front 59

Action/intention tremors

Back 59

Severe on sustained postures, worsen with action and use of writing/eating implements. Damange to cerebellar systems (particularly the hemispheres and dentate connections) often produces this kind that is most pronounced during voluntary actions.

Front 60

Postural (usually essential or familial) tremors

Back 60

Due to thyrotoxicosis, anxiety, caffeine, excessive symp/adrenal activity.

V. common, idiopathic, many cases are inherited.

Front 61

Myoclonus

Back 61

Sudden activ of muscles at rest. Can be due to encephalopathy

Front 62

Asterixis

Back 62

Sudden loss of muscle tone. Due to ecephalopathy/delerium. Many toxic, metabolic or drug related causes.

Front 63

Fasciculations

Back 63

May be normal, can happen with damage to lower motor neurons.

Can be benign. (often the case in calves)

Contraction of a single motor neuron unit. Don't result in movement of joint.

Also a sign of muscle overuse or irritation.

Front 64

Antalgic gait

Back 64

Caused by joint pain (often hip). Less time weight bearing on affected joint.

Front 65

Trendelenburg gait

Back 65

Unilat weakness of gip adductors and glutes.

Leaning to lesioned side with every contralateral leg swing.

Front 66

Waddling gait

Back 66

Proximal myopathy (osteomalacia and polymyosites, etc.)

Front 67

Fatiguing gait

Back 67

Myasthenia gravis

Front 68

High stepping giat

Back 68

Foot drop of proprioceptive loss

Front 69

Dragging leg of UML (stoke)

Back 69

scissor gait in CP

Front 70

Ataxic

Back 70

Cerebellar lesions. Broad based an leaning to lesioned side.

Front 71

Parkinson's gait

Back 71

Shuffling gait

Front 72

Apraxic gait

Back 72

Small magnetic steps
due to hydrocephalus or frontal lesions

Front 73

Astasia-abasia

Back 73

Gait of hysteria. They rarely fall. Not suggestive of a specific lesion.

Front 74

Reeling gait

Back 74

suggests cerebellar problems

Front 75

Apraxic gait

Back 75

fonrtal lobe disease

Front 76

Spastic-stiff legged

Back 76

Circumducting - drag one spastic limb around body.

Front 77

Lock-knees

Back 77

quadricep weakness

Front 78

waddling

Back 78

gluteal weakness

Front 79

Romberg sign

Back 79

Instability with eyes closed.

Due to sensory/proprioceptive loss

Front 80

gait in general

Back 80

the notes have a much better summary

Front 81

How do you differentiate an L5 radiculopathy from a peroneal nerve palsy?

Back 81

L5 results in pain and sensory deficits in the corresponsing dermatome.

Front 82

Neocerebellar lesions

Back 82

Ipsilateral intention tremor as determined by finger-nose and heel-shin testing.
ataxic gait
hypotonia in passive testing.

Front 83

Brainstem transection at midbrain above red nuclei

Back 83

Decorticate posturing (arms flexed, legs extended) to noxious stimulation

Front 84

Brainstem transection below red nuclei but above vestibular

Back 84

Decerebrate posturing (arms extended and pronated, legs extended) to noxious stimulation.

Front 85

Erb's palsy

Back 85

Paralysis of arm caused by lesion of C5-C7 (brachial plexus)

Front 86

Muscle disease vs. peripheral nerve disease

Back 86

Muscle disease - Symptoms are usually most evident proximally, there is no sensory loss, reflexes only affected late and atrophy is not severe.

Peripheral nerve disease - Effects of nerve damage are most often seen distally, reflexes are affected early and atrophy is often present

Front 87

With cerebellar damage, can reflexes be decreased?

Back 87

yes. muscle tone too.